Instructions
This case study consists of one
hypothetical patient situation.
Select the Patient Information tab. Within
this tab, you will be able to watch a video
to gain more insight regarding the patient
as well as view important patient details.
For this assignment, you will address a
series of questions regarding the care of
the patient. Your answers should include
specific reference to relevant guidelines
and other clinical information. The national
guidelines should also be considered with
treatment plans.
When you are done viewing the patient
information, download the Case Study
Assignment (Word) document from the
assignment page in Moodle. Use this document
to complete the assignment and then submit
it to the assignment page.
Patient Subjective Information
Histories
Past
Medical History
- Coronary Artery Disease – dx ("dx" is pronounced "diagnosed") age 76.
- Hypertension – dx ("dx" is pronounced "diagnosed") age 66.
- Osteoarthritis – dx ("dx" is pronounced "diagnosed") age 74
- Diabetes – dx ("dx" is pronounced "diagnosed’) age 68
Past Surgical
History
- Cholecystectomy – age 49
Psychiatric History
- No previous psychiatric inpatient care. Has previous history of taking an SSRI ("SSRI" is pronounced "SSRI") for short time several years ago for anxiety and panic related to grief after wife’s passing. Denies any suicidal ideation or past attempts.
- Denies any use of nonprescription medication. Denies any past history of trauma.
- None.
- Endorses seeing a therapist after his wife died and meeting in a grief group at church.
- None.
- Patient cannot recall: "I think it was something with a Z for anxiety and depression when my wife passed. I only took it for a few months to get through."
- Reports the therapist assisted him to consider his new life plan without wife. Group assisted him with moving on.
- Retired but worked in the corporate world for 30 years. Is used to being very active, and usually spends several hours per week helping out at the local hospital as a greeter and volunteer. He was unable to go for that last month due to feeling down. One daughter lives in a house down the street. He does not drive anymore, but usually visits his daughter daily. Denies history of tobacco, ETOH, or drug use.
- Father: Died age 76 (HTN)
- Mother: Died age 52 (Stroke)
- Brother: Died age 22 (WWII)
- Brother: Died age 80 (HTN, Asthma, DM)
- Denied
- Last colonoscopy @ at age 80.
- Last dental exam – one year ago.
- Last eye exam – six months ago.
- Pneumovax @ age 70
- Zostavax @ age 88
- Influenza – yearly
- Covid – last month
No recent travel outside the US.
Medications and Allergies
Medications
- Diclofenac sodium topical 1% gel, apply 4 grams QID ("QID" is pronounced "4 times per day) to both knees
- Atenolol 100mg po qd ("mg po qd" is pronounced "milligrams by mouth daily") x ("x" is pronounced "times") 15 years
- Aspirin 325mg po qd ("mg po qd" is pronounced "milligrams by mouth daily")
- Htz (hydrochlorothiazide) 12.5 mg po qd ("mg po qd" is pronounced "milligrams by mouth daily")
The patient discloses additional medications
only when his granddaughter leaves the room,
stating, "They think I may possibly also
have a slight case of Parkinson’s, so I
take: carbidopa/levodopa 25/250 mg
(milligrams) 1 tab PO TID ("PO TID" is
pronounced "by mouth three times per day")
and pramipexole 0.75mg (milligrams) 1 tab PO
TID ("PO TID" is pronounced "by mouth three
times per day"). The patient claims he
started this four weeks ago.
Allergies
- NKDA
Review of Systems
General: Reports usual health as
"pretty good."
- Denies headache.
- Denies blurred vision, difficulty with vision or double vision, eye pain, inflammation, discharge, lesions, loss of visual field, and history of glaucoma or cataracts. Does not wear corrective lenses.
- Denies hearing loss or difficulty, earaches, infections now or as a child, discharge, tinnitus, vertigo, or exposure to environmental noise.
- Denies nasal discharge, postnasal drip, sinus pain, nasal obstruction, epistaxis, or allergy.
- Denies mouth pain, bleeding gums, toothache, sores or lesions in mouth, dysphagia, hoarseness, or sore throat. Denies dentures.
- Denies neck lumps or swollen glands.
- Denies having h/o frequent infections, fevers, chills, or night sweats.
- Denies cough, sputum, hemoptysis, dyspnea, pleuritic chest pain, or wheezing. Denies past hx of lung disease, asthma, recurrent infections – bronchitis or pneumonia – or occupational exposures.
- Reports a history of atrial fibrillation for a short time, but it "corrected itself I am told." Denies chest pain or pressure, cyanosis, orthopnea, PND, SOB, DOE, or pedal edema. Denies history of heart murmur, claudication, hyperlipidemia, MVP, or rheumatic fever. States history of HTN and CAD.
- Denies recent change in appetite, recent weight gain/loss, nausea, vomiting, diarrhea, constipation, hematemesis, melena, BRBPR, change in stool caliber, or hemorrhoids, belching, flatus, or abd pain. Denies hx of hepatitis, peptic ulcer disease, gallbladder disease, dysphagia, GERD, or hernia.
- Denies dysuria, hematuria, nocturia, frequency, polyuria, incontinence, nephrolithiasis, UTIs, or pyelonephritis.
- Denies hx of unusually frequent or severe headaches, seizure disorder, stroke, or dizziness. Reports some weakness and some problems with mobility, but denies paralysis, difficulty speaking or swallowing, difficulty sleeping, or paresthesias. Not aware of memory problem. Denies h/o head injury.
- Reports a history of osteoarthritis with bilateral knee pain and hand pain that increases when he is active but gets better with rest and sometimes ice. Reports some stiffness in the morning or when he has been sitting for a while. Reports occasional decrease in mobility of the knees, which makes it difficult to get in and out of chairs or cars. Denies back or neck pain, myalgias, deformity, and muscle pain or weakness. Denies hx of gout, Lyme disease, or bone fracture. Does not use any assistant devices (cane or walker).
- Denies hx of phlebitis, varicose veins, claudication, cramping, or Raynaud’s disease, and pain or swelling in legs. Denies extremity coldness or discoloration.
- Denies polyuria, polydipsia, polyphagia, cold-heat intolerance, nervousness, or change in skin/hair/nails, appetite, or weight. Denies hx of thyroid pathology. States hx of DM but is well managed without medications, diet only.
- Denies hx of anemia, ease of bruising or bleeding, prior transfusions, lymph node enlargement or pain, fatigue, fever, chills, or night sweats.
Psychiatric ROS
Denies feelings of depression, but
reports feelings of panic and
anxiousness most of the day, with
worsening anxiety in late evening.
Anxious for the past three years,
with an increase in symptoms over
the past three to six months. Affect
is full ranging. Only feels
irritable when anxiety worsens;
denies feeling easily tearful.
Reports difficulty getting up in the
mornings when sleep has been poor.
Reports difficulty falling asleep
almost every night, and some
middle-night awakening.
No feelings of hopelessness,
helplessness, or hostility; denies
any feelings of guilt, shame, or
lack of motivation.
No loss of interest or pleasure in
activities, although reports he has
started to avoid some social
activities that cause him to feel
anxious.
No increased energy; reports feeling
fatigued most days, especially when
sleep is poor.
Some difficulty concentrating when
worrying, or with increased anxiety.
No increased or decreased appetite.
No self-inflicted injuries; no frequent thoughts of death, lack of desire to continue living, or suicidal tendency.
No homicidal thoughts.
No pressured speech, impulsive
behavior, feelings of grandeur, or
inflated self-esteem; not easily
distracted.
Racing thoughts throughout most of
the day – worsening in the late
afternoon and early evening; no
phobia or obsessive-compulsive
behavior. He has started missing
church and his volunteer work at the
hospital due to anxiety, but reports
he still tries to push himself to
attend as he knows others depend on
him.
No delusions, hallucinations,
feelings of persecution, hearing
sounds that seem to be voices, or
preoccupation with religion.
Objective
Physical Exam & Vital Signs
Mr. Bert Colton is an 89-y/o
Caucasian male who articulates
clearly but softly, ambulates slowly
without difficulty, and is in no
acute distress. General appearance
is same as stated age, with a normal
level of personal hygiene; no
inappropriate clothing, no bizarre
personal appearance.
- Ht: 69 inches
- Wt: 172 lbs.
- T: 98.6
- P: 78 irregular
- R: 18
- BP: 138/82
WNL by visual assessment, will defer
to PCP.
WNL by visual assessment, will
defer to PCP.
AP diameter 1:2; chest expansion
symmetric; tactile fremitus equal
bilaterally; lung fields resonant.
Vesicular breath sounds all lung
fields; no adventitious sounds.
S1-S2 irregularly-irregular rate and
rhythm, PMI at 5th ICS in LMCL, no
murmurs or rubs. No lifts, heaves, or
thrills. Peripheral pulses 2+ and equal
bilaterally. Nail beds pink and firm
with prompt capillary refill. Nails
without clubbing or discoloration. No
edema, varicosities, or calf tenderness.
WNL by visual assessment, will defer to
PCM.
Deferred to PCP.
TMJ without crepitus. Peripheral joints
with FROM without heat, redness,
swelling, or tenderness to palpation.
Neck and spine with FROM without pain.
No point tenderness of paraspinal
muscles. Muscle strength 4/5 for biceps,
triceps, quads, hamstrings, dorsi- and
plantar flexion. Noted bony enlargement
of both knees and in fingers in hands
bilaterally with limited full flexion
and extension; bilateral crepitus is
also noted.
Deferred to PCP.
- Warm, dry, with good turgor. No redness, cyanosis, or lesions.
Neurological
Mental Status Exam
Appearance, behavior, and speech appropriate. Thoughts coherent. Remote and recent memories intact.
Wrings hands when he speaks; no hypervigilance, heightened startle reflex, abnormal mannerisms, or uncommunicative/disinterested/hostile/inattentive attitude.
No tremor or tics; normal gait and stance; no involuntary movements.
No refusal to speak or loosening of association/word salad; not slowed, rapid, or difficult; normal rhythm of speech, speech tone, and speech volume.
Not dysthymic or depressed; appears moderately anxious, not dysphoric, euphoric, angry, elevated, or expansive.
Full-ranging, not blunted or
constricted.
No language abnormalities; speech fluent; no dysphonia; no stuttering; language fluent and intact for naming; normal sentence structure.
Patient oriented x3, no disorientation, short-term memory impairment, or reduced abstraction ability; diminished cognitive functioning only when anxiety is intense.
No deficiency on evaluation of connectedness; organized.
No thought content impairment; no suicidal ideation, homicidal ideations, paranoid ideations, poverty of thought, thought insertions, obsessions, irrational fears, delusions, or hallucinations.
No impaired insight, impaired judgment, or poor problem solving.
CN II through XII intact.
Resting tremor left upper extremity noted, which resolves with holding pencil. Noted to have "pill rolling" in bilateral thumbs to index finger while ambulating. Gait is slightly uneven but coordinated and steady. Unable to walk on heels/toes without stabilizer (counter). Did not attempt squat and tandem walk due to OA of knee. Cerebellar: RAM intact; finger-to-nose smoothly intact but slow progression.
Pinprick, light touch, vibration intact. Stereognosis; able to identify key and coin.
Brachioradialis, biceps, triceps, patellar, and Achilles 2+/4+ bilaterally; no ankle clonus. Plantar: toes down going.
Lab Values
Diagnostic Studies:
| Lab Test | Result | Normal Range |
|---|---|---|
| TSH | 3.8 | 0.35–5.5 mcU/ml |
| Free T4 | 1.5 | 1.0–2.3 ng/dl |
CBC w/
diff
| Test | Patient Result | Normal Range |
|---|---|---|
| WBC | 9.7 | 4.8–10.8 K/uL |
| RBC | 4.9 | 4.7–6.1 106/mm3 |
| Hgb | 14.5 | 13.6–17.5 g/dl |
| Hct | 42 | 39%–49% |
| MCV | 82 | 80–100 μm3 |
| MCH | 29 | 26–34 pg |
| MCHC | 35 | 31–36 g/dl |
| RDW | 13.5 | 11.5%–14.5% |
| Platelets | 229 | 150–450 K/uL |
| Neutrophils | 44 | 40%–60% |
| Lymphocytes | 28 | 20%–40% |
| Monocytes | 5 | 2%–8% |
| Eosinophils | 3 | 1%–4% |
| Basophils | 0.5 | 0.5%–1% |
| Bands | 2 | 0%-3% |
CBC w/
diff
| Test | Patient Result | Normal Range |
|---|---|---|
| Sodium | 146 | 135–145 mEq/L |
| Potassium | 3.9 | 3.5–5.2 mEq/L |
| Chloride | 106 | 96–106 mEq/L |
| Carbon Dioxide | 24 | 20–29 mEq/L |
| Glucose | 98 | 74–106 mg/dl |
| BUN | 19 | 7–20 mg/dl |
| Creatinine | 1.15 | 0.8–1.4 mg/dl |
| Calcium | 9.2 | 8.5–10.2 mg/dl |
| Total Protein | 6.9 | 6.0–8.3 gm/dl |
| Albumin | 4.9 | 3.4–5.4 g/dl |
| Total Bilirubin | 0.9 | < 1.9 mg/dl |
| Alkaline Phosphatase | 66 | 44–147 units/L |
| AST | 27 | < 40 units/L |
| ALT | 32 | < 40 units/L |
| GGT | 20 | 0-42 units/L |
Fasting
Lipid Panel
| Test | Patient Result | Normal Range |
|---|---|---|
| Total Cholesterol | 168 | < 200 mg/dl |
| Triglycerides | 121 | < 150 mg/dl |
| HDL | 59 | >40 mg/dl |
| LDL | 99 | < 130 mg/dl |
Urinalysis
| Test | Patient Result | Normal Range |
|---|---|---|
| Color | Yellow | |
| Appearance | Clear | Clear |
| Specific Gravity | 1.020 | 1.003–1.030 |
| pH | 6.8 | 5-7 |
| Bilirubin | Neg | Negative |
| Blood | Neg | Negative |
| Glucose | Neg | Negative |
| Ketones | Neg | Negative |
| Leukocyte Esterase | Neg | Negative |
| Nitrite | Neg | Negative |
| Urobilinogen | 1.0 mg/dL | < 2.0 mg/dL |
| Protein | Neg | Neg-trace |
| WBC | 0–1 | 3/hpf |
| RBC | 0–1 | 3/hpf |
Questions
- Differentials: List the three most likely differential diagnoses based on her objective findings, with cited rationale.
- What is the etiology/pathophysiology associated with each diagnosis?
- What is the prevalence of each of these diagnoses?
- Develop a plan of care for each of
the three differential diagnoses,
including
the following:
- Diagnostic testing
- Pharmacologic interventions, including dosage, route, and frequency
- Nonpharmacologic interventions, including modality and frequency
- Education, including health promotion, maintenance, and psychosocial needs
- Safety plan
- Referrals required
- Follow-up, including return to clinic (RTC) in what time frame and reason, including any labs needed for next visit
You
have completed
this activity.